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Author
Topic: medical records patients rights. (Read 4875 times)

was wondering if a patient has the right to have a doctor exclude reports/test results from ones medical record.i could probably google this but thought someone here would be able to spell it out in simple terms. (also kinda tired lately.)wah, wah.

I'm not sure that you can "force" them too -- and I'm not sure that a doctor would even want to do so, from a legal point of view.I'm sure there are others, Basquo perhaps, who will know better than I -- but I believe your medical record is actually "owned" by the clinician -- it's a record of the care he/she has provided. That is why I think there might be a legal issue with removing something from it.

I don't know the laws/standards either. I wouldn't think they could just trash something in your medical report.

I do remembering signing documents about what can be shared with others, and you could write in things you don't want shared. For example, when another doc, government agency, lawyer, or even the person you have designated to have access to your medical records requests medical records. I know HIV tests were on there, among other things. Usually, they list various things that you check off as being allowed to share.

So, I know you can instruct certain things to not be shared, but wouldn't think they could just delete it totally. Perhaps not sharing with others is what you meant by excluding, and didn't mean get rid of the info altogether.

Thanks guys.Here is a bit more backround...I had a neuropsychological test done.I kinda was pushing my ID doc for the referral due to cognitive/memory issues.Had no idea how the test was "graded".It turns out that it is graded on a bell curve.If you fall below the bottom 16%, you are considered impaired.So, if you test at 19% on a memory test, you are considered "normal" even though 5 years ago you might have tested at a 82% level.The test was long and pretty silly IMO.

The other reason that I wanted the test was to help bolster my ssdi case.Guess THAT was a bad idea.It will do nothing but hurt my case.

A copy was sent to my ID doc.THIS is the one that I would like to get removed. (not the original one with the neuropsychologist)

My Psychiatrist thought the test and related commentary was inaccurate and told me to ask my ID doc to remove it from my records.I asked her if I could legally do that but I really didn't get a clear answer.She KNOWS I am disabled and is 100% on my side.Her report to ssdi was very strongly worded on my behalf.

I might have to hope that my ID doc will "lose" the report so I can pretend it never happened?

I'm sure I signed some sort of release papers. It's hard to avoid it and I really wasn't thinking about the possible outcome of the test at the time. My bad.

If I remember correctly, the SSA does not request paperwork from doctors unless it's a SSA doctor that they send you to. Since it's up to you to provide any evidence to them, can't you simply exclude that report?

If I remember correctly, the SSA does not request paperwork from doctors unless it's a SSA doctor that they send you to. Since it's up to you to provide any evidence to them, can't you simply exclude that report?

on my first application the ssdi requested a list of my docs and got a medical report back from most of them.i am at the appeal stage now.(i am realizing now that this might have been better posted in the disability forum, duh... see, this is how fuzzy my brain is working. .)

i certainly will not be mentioning that report but am afraid that if they request reports from my ID doc, he might feel obligated to provide it.

I am certain that this issue would be only a part of the whole information to be considered ... and if Im reading what you wrote about it correctly it seems as if the test was inconclusive instead of something that would help or hurt your case since its only a part of the overall report on whats going on with you .

From knowing many people signing up or getting SSDI, it was my understanding it was your right to only include information that would help your case, except for the docs they send you to. In fact, I know a few said social security said they could request the medical reports, or they could collect it and send it. In that case, you could just pull out info you don't want sent. Actually, the KY SSDI office often asked patients or their lawyers to get the info, either to save them work, or because they said the doc never responded to their requests.

Perhaps a disability lawyer would answer a quick question on the phone. I know when I've had simple questions, lawyers would answer them.

I am certain that this issue would be only a part of the whole information to be considered ... and if Im reading what you wrote about it correctly it seems as if the test was inconclusive instead of something that would help or hurt your case since its only a part of the overall report on whats going on with you .

yes, while i have other factors involved, his report under "recommendations" states:

"he maintains normal functional capacitythat, even if it is not the same as when he was much younger, it is sufficient to be quite functional."

"....having reported a dry mouth. This is a typical anticholinergic side effect of some medications and is often associated with verbal memory complaints. His medications should be reviewed and medications that may be contributing to this should be reduced if possible."

"it would be useful for him to reengage life, perhaps by returning to work on a part-time basis."

"It would be a good opportunity for him to test some of the assumptions he has made over the recent past concerning his true capabilities."

geez, a couple of hours of taking a silly test and he "knows" everything about me and how to solve my problems. Quack!(i was getting more upset even typing what he wrote .)

If I understand, you went to this doc, rather than social security sending you to him. I know SS asks applicants what docs they want medical records used from. I would just not mention this docs name. If the report is now in your files at your ID doc as the referring doc, I think you could request that report never be shared, because it was not performed by your ID doc.

I know so many docs think working would magically solve all problems. I suppose they think not working has slowed people, physically and mentally. They don't realize things are so much more complicated than that. Most I know on disability would love to be able to work. They miss it. They miss having that social aspect outside of home. But, they have health problems that make it impossible. Even if they could get hired, they would likely lose the job, because they just aren't able to do it, with their disabilities.

If I understand, you went to this doc, rather than social security sending you to him. I know SS asks applicants what docs they want medical records used from. I would just not mention this docs name. If the report is now in your files at your ID doc as the referring doc, I think you could request that report never be shared, because it was not performed by your ID doc.

I know so many docs think working would magically solve all problems. I suppose they think not working has slowed people, physically and mentally. They don't realize things are so much more complicated than that. Most I know on disability would love to be able to work. They miss it. They miss having that social aspect outside of home. But, they have health problems that make it impossible. Even if they could get hired, they would likely lose the job, because they just aren't able to do it, with their disabilities.

Interesting question, mitch777.If I'm reading this correctly, you had a neuropsych exam that showed that you had some cognitive impairment, but still some residual functional capacity. You're worried that this report will hurt your SSDI case, and want your ID doctor to exclude it from your medical record. First thing is that, if you are already at the appeal stage, SSA should already have all your evidence, so unless they already have it, the only way they can get it is for you to submit it. If they already have it, though, they will consider it. There's no way to withdraw it if it is relevant to your claim.If your claim is based on something other than cognitive impairment, ie you've had multiple OIs, or you have enough other manifestations of HIV infection, then the exam would not be relevant to your claim, and SSA will not consider it.If they have it and they are going to consider it, you can always have your psychiatrist (the one who disagrees with the report) write her own assessment, which you could then submit.If your ID doctor decides that the report is not relevant to your HIV treatment, he can legally exclude it from the records he maintains as long as he did not prepare the report himself.

Logged

It goes like thisThe fourth, the fifth,The minor fall, the major lift,The baffled king composing Hallelujah!

Most I know on disability would love to be able to work. They miss it. They miss having that social aspect outside of home. But, they have health problems that make it impossible. Even if they could get hired, they would likely lose the job, because they just aren't able to do it, with their disabilities.

Interesting question, mitch777.If I'm reading this correctly, you had a neuropsych exam that showed that you had some cognitive impairment, but still some residual functional capacity. You're worried that this report will hurt your SSDI case, and want your ID doctor to exclude it from your medical record. First thing is that, if you are already at the appeal stage, SSA should already have all your evidence, so unless they already have it, the only way they can get it is for you to submit it. If they already have it, though, they will consider it. There's no way to withdraw it if it is relevant to your claim.If your claim is based on something other than cognitive impairment, ie you've had multiple OIs, or you have enough other manifestations of HIV infection, then the exam would not be relevant to your claim, and SSA will not consider it.If they have it and they are going to consider it, you can always have your psychiatrist (the one who disagrees with the report) write her own assessment, which you could then submit.If your ID doctor decides that the report is not relevant to your HIV treatment, he can legally exclude it from the records he maintains as long as he did not prepare the report himself.

Thank you JR!Your last sentence answered my question. The SSA does not yet have a copy of the report. While a portion of my claim states that I believe I have cognitive issues, it is by no means the whole picture.Daily chronic headaches are one issue. (non-HIV related... I think. Neurologist thinks they are caused by 2 bulging disks in my neck.)No OI's and my numbers are good. The major issues related to HIV are: Severe fatigue. (sleep about 11 hours per day)

Weakness in limbs. (often have difficulty standing or walking for more than 15-30 minutes)

Cognitive and memory issues. (I may have been within this guys "bell curve" but KNOW that I am FAR from how I was able to think and remember just a few years ago)

Social activity is a rare occurrence and daily activities are at a bare minimum. (pretty much home bound other than a rare night out, 50-60 medical related appointments per year, and grocery shopping)

Depression.

I think I may have to rely on my Psychiatrist and my Neurologist more than my ID doctor for my case as it seems the SSA doesn't put much weight on my HIV.Sad, angry, tired and frustrated at the same time.

If you have any more advice...

(I have had an attorney from the beginning but I sometimes wonder how good she is with a disability case.I tried calling MANY disability attorneys in the beginning but none wanted to be bothered with someone who was self-employed.)I'm stuck with who I have at this point and she did refer me to my psychiatrist who I like allot and has been very understanding and helpful with my claim.

Anyway,thanks again for taking the time!I will be sure to ask my ID doc to pull that report from his records.